Completing an AIR (anti-inflammatory reliever) asthma action plan with your patients

These guidance notes are for our AIR asthma action plan which is for patients who are on an AIR (anti-inflammatory reliever) inhaler containing ICS-formoterol, without maintenance doses.

We also have guidance notes for patients on a MART treatment plan who take ICS-formoterol every day as maintenance, and as required when they get symptoms.

If your patient has been prescribed a preventer inhaler, or combination inhaler with a separate SABA reliever inhaler, please refer to our preventer/reliever asthma action plan guidance notes.

Our action plans are available in print or as a free digital download. We also have a printer-friendly black and white version you can download. Our adult action plans are translated into a range of languages.

Find all our asthma action plans here.

An anti-inflammatory reliever, known as AIR, is a combination inhaler containing an inhaled corticosteroid and formoterol.

AIR is only prescribed to adults and children 12 years and over.

Your patients might benefit from an AIR inhaler if:

• they only get asthma symptoms occasionally (usually no more than twice a month)  and are not taking a regular preventer
• they get seasonal asthma which means they only use a preventer inhaler at certain times of the year, or for specific triggers they come into contact with only occasionally
• they have been using a blue reliever (salbutamol) only.

Our AIR asthma action plan is only for steroid inhalers that also contain formoterol. The only inhaler licensed for as-needed use of ICS/formoterol is Symbicort 200/6.

Underuse and overuse of SABA are known risk factors for asthma deaths.  

An AIR treatment plan can benefit you and your patients:

• An AIR inhaler relieves asthma symptoms quickly AND treats the underlying inflammation that causes symptoms. 
• Use of an AIR inhaler has been shown to lower the rate of asthma exacerbations and hospitalisations compared to SABA only. 
• Each puff of an AIR inhaler contains a low dose of an inhaled corticosteroid, which lowers the risk of asthma attacks requiring high dose steroid tablets. This lowers an individual’s steroid load overall.  
• AIR allows for easy transition to a MART regime for a period of time if appropriate, for example during winter, or pollen season. 
• An AIR treatment plan requires a single combination inhaler. This means fewer inhalers are prescribed which is cheaper for patients and better for the environment.

You can signpost your patient to patient-facing health advice about AIR on our website.

In between regular asthma reviews, your patients need to know what to do to manage their asthma well.   

An AIR asthma action plan can help your patient understand how to use their new inhaler, and can help you see if an AIR inhaler is working well for them.

It tells your patients:

• when they need to take their inhaler
• what to do if their asthma symptoms get worse or are happening more often
• what emergency action to take if they have an asthma attack.

An asthma action plan supports patients to take the right actions at the right time and lower their risk of a potentially fatal asthma attack.

Use our guide to help you complete our AIR asthma action plan with your patient and any carers.

Once your patient’s plan is complete and up to date, save a copy to their notes. It’s important to replace any older plans with a newly updated one. Ask how your patient would like you to share the plan with them, either electronically, or as a print copy.

Section 1: Everyday asthma care (green)

• Tell patients the name of their AIR inhaler and write this down in the space provided.
• Explain that they should take their AIR inhaler only as needed when they get asthma symptoms. 
• Advise your patients to carry their AIR inhaler with them every day so they can use it if they get asthma symptoms. 

Help your patients understand how to use their AIR inhaler: 

• They should take one puff if they get symptoms. 
• If after a few minutes they still have symptoms, they can take another puff.  
• Write down the maximum number of puffs they can take at any one time. 

You can find this information in the medicine prescribing details on the British National Formulary website. 

Use the space at the end of this section to list any other advice, including medicines and devices your patient uses to manage their asthma symptoms, such as antihistamines, nasal sprays, or peak flow meters. 

When completing this section:

• Reassure patients that their AIR inhaler contains formoterol which is a medicine that can quickly open the airways in the same way that the blue SABA reliever does. 
• Explain that they do not need a second inhaler but should always carry their AIR inhaler with them in case they get asthma symptoms. 
• Let them know that their AIR inhaler also gives a small dose of anti-inflammatory steroid medicine, which can help reduce inflammation in the airways and prevent more symptoms and asthma attacks.  
• Stress the importance of good inhaler technique. Show them the best way to use their AIR inhaler, signpost them to our inhaler technique videos and let them know that their pharmacist can also help. 
• Share a link, or print out, our patient-facing health advice page about AIR. 

Section 2: When I feel worse (amber)

• Talk to your patients about the signs and symptoms that indicate their asthma is getting worse.
• Make sure patients understand what action to take if their asthma is getting worse.
• Make sure they know the maximum daily number of puffs for their AIR inhaler. Write this down in the plan. Consult the BNF (British National Formulary).

Advise patients to contact their GP or nurse if: 

• they need to use the maximum daily dose of their AIR inhaler and their symptoms are not improving 
• they’re using doses of their AIR inhaler most days. Advise your patient when they should seek help if this is the case.   

Based on your knowledge of your patient, you may want to set additional thresholds for seeking help for taking action. 

There is a box at the end of section 2 where you can write down other advice for if their symptoms worsen. 

If your patient is using doses of their AIR inhaler most days, consider whether MART would be more appropriate.

Rescue packs of oral steroids 

In most cases it is more appropriate for a patient whose asthma symptoms are flaring up to be assessed by a health professional. But occasionally a patient may be prescribed a rescue pack of oral steroids (usually prednisolone) to keep at home. 

Ensure that they have clear, written instructions on when to start taking the medicines, at what dose, and for how long. 

Make them aware that they need to see their GP or nurse:

• as soon as possible after starting the course 
• urgently if their symptoms get worse or their peak flow drops
• if they don’t feel better before the end of the course.

BTS/SIGN Guidelines for adults suggest 40-50mg daily of prednisolone for at least five days, or until recovery. 

When completing Section 2:

• Stress the importance of acting quickly to avoid symptoms building up into an asthma attack. 
• Talk to them about the best way to navigate the urgent appointment system at their GP practice, and suitable alternatives, such as calling 111, or accessing local walk-in centres.

Section 3: In an asthma attack (red)

Make sure your patient, and anyone caring for them, can recognise signs of an asthma attack and when they need to take action. 

This section sets out:

• The signs and symptoms of an asthma attack
• What to do in an asthma attack
• When to call 999 
• When to contact their GP after an attack.

It is essential that you protect your patient by giving them clear instructions about using their AIR inhaler if they have an asthma attack, and when to seek urgent or emergency help, including:  

• how many puffs to take of their AIR inhaler if their symptoms flare up
• how long they should wait between puffs
• when to call 999 if there is no improvement
• how many puffs to continue taking while waiting for the ambulance.

Make sure your patient understands that they need to follow the asthma attack advice below which is specific to their AIR inhaler.

What to do if you have an asthma attack (AIR)

1. Sit up straight - try to keep calm. 
2. Take one puff of your AIR inhaler every 1 to 3 minutes up to six puffs. 
3. If you feel worse at any point OR you do not feel better after six puffs call 999 for an ambulance. 
4. If the ambulance has not arrived after 10 minutes and your symptoms are not improving, repeat step 2. 
5. If your symptoms are not better after repeating step 2, and the ambulance has still not arrived, contact 999 again immediately. 

If you do not have your AIR inhaler with you, call 999.

Inform patients that if they call 999 for help, they should tell the call-handler that they use an anti-inflammatory reliever inhaler. 

When completing Section 3, emphasise the importance of:

• seeking help urgently by calling 999 if their inhaler is not helping 
• getting a same-day appointment with their GP or nurse if they managed an asthma attack at home 
• booking a follow-up appointment with their GP or nurse within 48 hours of being discharged if they went to hospital with an asthma attack 
• finishing any medicines they have been prescribed 
• speaking to their doctor, nurse or healthcare professional urgently if they do not feel better after treatment.  

A post-asthma attack follow-up should look at what triggered the asthma attack, review the patient’s treatment plan and inhaler technique, and discuss ways to reduce the risk of future attacks.  

Talk to your patient about the best way to navigate the urgent appointment system at their GP practice, and suitable alternatives, such as A&E, 111, or local walk-in centres. 

Peak flow – All sections

In all three sections, there is an option to add your patient’s peak flow scores.

• In section 1 you can note down your patient’s personal best score – the score that is usual for them when they are well. Your patient needs to have kept a peak flow diary for at least two weeks to establish a best score. 
• In section 2 note down the peak flow score suggesting worsening asthma symptoms. This is a score that is lower than their personal best score. 
• In section 3 note down the peak flow score signalling an asthma attack.

Not all your patients will be using peak flow long term to manage their asthma. Monitoring peak flow at home is most useful at key times, such as during and after an asthma attack, or if your patient’s treatment plan has changed.

Peak flow is not a substitute for a good clinical history. Do not rely on peak flow in isolation.

If your patient is using peak flow monitoring as part of their asthma management plan, whether that’s in the short or long term, it is important to make them aware that:

• Peak flow scores do not always change when symptoms get worse. It’s important to take action when symptoms worsen, whatever their peak flow score. For example, if they’re having symptoms at night or on waking, they need an urgent assessment, even if their peak flow score is the same. 
• Peak flow can pick up changes in the airways before they have symptoms. If your patient’s peak flow score is lower than normal, it could be an early sign that their asthma is getting worse, and they should seek help and advice.  

You can signpost your patient to our page on peak flow for more information and advice.

• A personal best peak flow score, or a score that is at least 80% of their personal best score, indicates well-controlled asthma.   
• A peak flow 75% or below their best score will require optimisation of care and self-care if this persists. 
• A peak flow below 50% or below their best score indicates that your patient might be having an asthma attack, and they should take urgent action.  

Asthma triggers

Write down any triggers and allergies that you and your patient have identified in the ‘My asthma triggers’ section of the asthma action plan.

Stress the importance of minimising their risk by:

• always carrying their AIR inhaler with them 
• avoiding their triggers when possible, including cigarette smoke, air pollution and pets 
• managing hay fever with antihistamines 
• understanding that if exercise triggers symptoms, it can be a sign of poor asthma control and they should see their GP or nurse 
• taking extra care if they have a known food allergy, which can make asthma attacks more serious.  

You can signpost your patients to our asthma triggers pages for more information and advice about triggers.

Asthma review

In the ‘My asthma review’ section of the plan, there is space for you to write in your patient’s next review date.

When considering the timing and frequency of asthma reviews, consider: 

• your patient’s level of asthma control and if they need a review more frequently than once a year 
• the pattern of their asthma symptoms and when they tend to be worse - for example, in response to seasonal triggers  
• your patient’s preferences and ease of attending review appointments - for example, if they work, or have children or other dependents to consider
• whether you can safely conduct an asthma review online or over the phone 
• setting up repeat prescriptions based on your predictions of how long their inhaler should last. Keep in mind that with AIR, it may be hard to predict how long each inhaler will last, because the use will vary from person to person, so it is essential to set up the prescription so that it offers flexibility. 
   

Your patient’s AIR asthma action plan is designed to be an easy to refer to self-management tool. 

To help your patient use their plan effectively, you could:

• advise them to keep a copy of their updated plan on their phone, tablet or laptop. You could email them an electronic version. If this is not possible, they could they take a photo of the plan to keep on their phone. Remind them to replace it each time their plan is updated.
• encourage your patient to keep a printed copy on their fridge or somewhere obvious, so it reminds them what they need to do to stay on top of their asthma.
• suggest your patient shares their asthma action plan with friends, family and colleagues. They could send them the photo on their phone or tell them where a paper version is kept. This could be lifesaving if your patient experiences an asthma attack.
• remind them to bring their plan along to every appointment.

A written asthma action plan is only one part of helping your patients maintain good control of their asthma.

Pinnock and Taylor explain the application of PRISMS to people with asthma (PDF), which includes:  

• giving patients information about their asthma – for example, signposting them to the Asthma + Lung UK website
• letting them know about the Asthma and Lung UK Helpline.
• encouraging patients to make the most of a supportive community, such as the Health Unlocked asthma community forum, where they can share experiences and get support from others with asthma, and the Asthma + Lung UK support groups.

Find all our asthma action plans, which are available in a range of languages, on our healthcare professionals resources pages. They are free to download or order.